This brief was prepared by the Urban Institute under contract with the Office
of the Assistant Secretary for Planning and Evaluation. Authors are
Karina Fortuny and Ajay Chaudry, who contributed to this brief while at the
Urban Institute.

This Issue Brief is available on the Internet at:
http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml

The Immigrant Access to Health and Human Services project maps and describes
the legal and policy contexts that govern and affect immigrant access to
health and human services. Through a synthesis of existing information,
supplemented by in-depth visits to purposively selected sites, the study
aims to identify and describe federal, state, and local program eligibility
provisions related to immigrants, major barriers (such as language and family
structure) to immigrants access to health and human services for which
they are legally eligible, and innovative or promising practices that can
help states manage their programs.

Immigrants access to health and human services is shaped by complex
federal rules on eligibility and differences in state and local policy and
practice.[1] The 1996 Personal
Responsibility and Work Opportunity Reconciliation Act (PRWORA), also known
as welfare reform, introduced restrictions for federal means-tested benefits
related to immigration status and length of U.S. residence. Welfare
reform and later legislation set parameters for states use of federal
and state funding and increased states authority in administering public
benefit programs. The resulting federal and state provisions regarding
immigrants access to health and human services have created a patchwork
of complicated and often confusing eligibility rules, and in policies and
practices that vary across benefit programs and states.

These complexities in eligibility provisions and state and local variation
in policy and implementation create the need for a timely and up-to-date
study that describes the policy context affecting immigrant access to public
benefits. This brief, part of the Immigrant Access to Health and Human
Services study, describes key federal and state immigrant eligibility provisions
to help inform policymakers, program administrators, and communities serving
immigrant families and children.

Beyond eligibility restrictions, immigrants face other barriers in accessing
public benefits, including lack of knowledge about the programs, confusion
about the eligibility requirements, language and cultural sensitivity issues,
and fear of adverse immigration consequences. Other issue briefs in
this study further explore barriers to access and promising practices that
appear to facilitate access.

While many immigrants who are lawfully present in the United States are eligible
for public benefits, there are restrictions based on citizenship and immigration
status that limit their access to several federal means-tested programs.
These include many of the programs intended to support work, economic stability,
nutrition, and health for low-income children and families: Temporary
Assistance for Needy Families (TANF), the Supplemental Nutrition Assistance
Program (SNAP),[2] Medicaid, and the
Childrens Health Insurance Program
(CHIP).[3] Historically, unauthorized
immigrants were ineligible for federally funded assistance, but welfare reform
in 1996 also restricted access for lawfully present immigrants based on their
immigration status, when they arrived in the United States, and length of
U.S. residence.

PRWORA established two categories of immigrants: qualified immigrants,
including lawful permanent residents (LPRs), refugees, and other protected
immigration statuses; and nonqualified
immigrants.[4] Nonqualified is
not synonymous with unauthorized immigrant status. The group of
nonqualified immigrants for public benefit eligibility combines various
immigration categories, including lawfully present immigrants such as students
and tourists, immigrants in protected statuses such as asylum seekers, and
unauthorized immigrants (see figure 5 for definitions).

The second important provision of welfare reform was to make a distinction
for qualified immigrants arriving prior to the enactment of PRWORA (August
22, 1996) and those arriving after, and to further divide the latter group
into those with five or fewer years versus more than five years in the United
States in qualified status. Welfare reform limited access to public
benefits for post-PRWORA immigrants with less than five years of qualified
status, also called the five-year ban. Select groups of immigrants
are exempt from the five-year ban: refugees, asylees and other immigrants
exempt on humanitarian grounds;[5] and
members of the military and veterans (and their spouses and children).

PRWORA also set parameters for states ability to administer public
benefit programs. First, states can use state funding to cover qualified
immigrants during the five-year ban to replace the loss of SNAP, TANF, and
Medicaid benefits. States can also provide state-only-funded assistance
to nonqualified immigrants. Second, outside of the five-year ban, states
are required to cover certain immigrants: refugees and asylees, LPRs
with 40 qualifying quarters of work, and members of the military and veterans
(and their spouses and children). But states can determine whether
other qualified immigrants are eligible for TANF and Medicaid (Broder and
Blazer 2010; Fix et al. 2009; Fortuny and Chaudry, 2011).

Detailed information on eligibility under federal law for the specific
immigration categories for each program is available in the comprehensive
review of literature developed for this study (Fortuny and Chaudry
2011).[6] Some special provisions
enacted since 1996 apply to children and pregnant women and are worth
highlighting. Since 2002, qualified immigrant children are not subject
to the five-year ban for SNAP benefits. Since 2009, children and pregnant
women can be eligible for Medicaid/ CHIP, including during the five-year
ban, if they reside in a state that has chosen to extend coverage under the
Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA).

Under CHIPRA, states can receive federal funding to provide Medicaid and/or
CHIP to lawfully residing children up to age 21 and pregnant women for 60
days postpartum, including during the five-year
ban.[7] The lawfully present group
that states can cover is a broader group than the qualified immigrants group
as defined by welfare reform. States choosing this option can provide
coverage to children only, to pregnant women only, or to both, and can do
so through Medicaid only or through both Medicaid and CHIP (NILC
2010a).[8] States that have chosen
this option are discussed in the Medicaid section below.

States can cover immigrants with substitute SNAP, Medicaid, and TANF benefits
using their own funding and since 2009, states have the option of covering
lawfully present children and pregnant women in Medicaid and/or CHIP.
The key state provisions include whether to
provide:[9]

As of July 2009, nearly half of the states (22 states) provide state-only
funded cash assistance to some or all qualified immigrants during the five-year
ban (figure 2). All nonexempt qualified immigrants
were covered in 16 states, while in the remaining six states only certain
immigrants, (e.g., battered spouses and children) were covered (Rowe, Murphy,
and Mon 2010).[11]

In addition, five states (California, Hawaii, Minnesota, New York, and
Washington) provide state-only funded assistance for some nonqualified
immigrants. For example, California and Hawaii provide assistance to
most nonqualified lawfully present immigrants and Minnesota, to persons in
temporary protected status (Rowe et al. 2010).

Source: Fortuny and Chaudry (2011); Rowe
et al. (2010).Notes: Data are as of July 2009.
Information on state rules is limited to cash assistance only.
The Welfare Rules Database includes information on state benefits provided
under separate state programs or state-only-funded programs,
but only when the benefits are considered part of the same basic program
by the state.
Thus, the eligibility rules might not include all state-only-funded
programs.

As of March 2011, 22 states and the District of Columbia have chosen to provide
Medicaid and CHIP to lawfully present immigrant children and pregnant women
who meet the Medicaid state residency requirement (figure
3). Most states cover both children and pregnant women. Five
states (Iowa, Montana, Oregon, Rhode Island, and Virginia) cover only children,
while one, Colorado, provides coverage to pregnant women
only.[12]

In addition, states can provide prenatal care to immigrant women otherwise
ineligible for Medicaid and/or CHIP under the CHIP unborn child option using
federal matching funds (Kaiser Commission on Medicaid and the Uninsured 2009,
figure
3).[13] Eligibility for
this coverage does not depend on the womans immigration status and
is limited to pregnant women only. As of July 2010, 14 states provide
prenatal care, labor, and postpartum care to immigrant women under this
option. Six states (California, Massachusetts, Minnesota, Texas,
Washington, and Wisconsin) have chosen both the CHIPRA option for lawfully
present immigrant women and the CHIP option for nonqualified immigrants.

Health coverage for immigrants during the five-year ban is limited to children
and pregnant women under CHIPRA in most states, but 14 states and the District
of Columbia provide state-only-funded health coverage to immigrants other
than children and pregnant women (figure 4). State-only funded health
coverage is limited based on age, immigration status, disability, and other
criteria. For example, Washington provides medical assistance to qualified
immigrants who are seniors and persons with disabilities and receive state-only
cash assistance (NILC 2010b, 2010c).

Sixteen states and the District of Columbia also provide some health coverage
to select groups of nonqualified immigrants using state-only funding.
Coverage varies and, in many instances, is limited depending on age, immigrant
status, and disability status (NILC 2010b, 2010c). Most of these states
are among the states that also provide state-only health coverage to qualified
immigrants.

California, Minnesota, and Washington are the only states that provide all
five types of assistance. Several more states (Connecticut, Hawaii,
Illinois, Maine, Massachusetts, Nebraska, New Jersey, New Mexico, New York,
Oregon, Rhode Island, and Wisconsin) provide three or four of the five types
of assistance.

The complexity of federal eligibility provisions and states choices in extending
or further restricting coverage for immigrants within the federal framework
contribute to vast differences in the ease of access to and participation
in public benefits of immigrants across the United States. As a result,
income-eligible immigrant families and children have lower rates of participation
in the major means-tested programs than families of U.S. citizens and this
participation gap varies widely depending on where immigrants live (Capps
et al. 2009; Capps and Fortuny 2006; Chilton 2007; Cunnyngham 2004; Henderson
et al. 2008; Kenney et al. 2010; Perreira and Ornelas 2011). But
restrictions to eligibility based on immigration status are just one side
of a multifaceted story  a story where eligibility provisions
for benefits intersect with policies on immigrants social and economic
integration, and states efforts in facilitating access for hard-to-reach
populations (Perreira, et al., forthcoming; Crosnoe, et al., forthcoming).

The recent field research for this project in several states reveals that
many of these barriers persist (Perreira, et al., forthcoming). The
study identifies several factors that matter greatly for immigrant families
applying for and enrolling in public benefit programs and that vary widely
across the states: complexity of the application process, documentation
requirements, and eligibility rules; literacy, language, and cultural sensitivity
barriers; transportation and other logistical barriers; the enrollment process
and renewal; and climates of misinformation, mistrust, and fear (Perreira,
et al., forthcoming). These barriers can be especially pronounced for
mixed-status families where unauthorized immigrant parents need to navigate
the system on behalf of their U.S. citizen children (Henderson et al. 2008;
Perreira, et al., forthcoming; Perreira and Ornelas 2011).

Table 1.
Summary of State Medicaid and CHIP Provisions and State-Only Coverage

State

Federal Medicaid and CHIP Options

State-Only Coverage

Lawfully residing children and/or pregnant womena

Pregnant women under the CHIP unborn child optionb

Food assistancec

Cash assistanced

Health coveragee

Alabama

Alaska

X

Arizona

X

Arkansas

X

California

X

X

X

X

X

Colorado

X

Connecticut

X

X

X

Delaware

X

X

District of Columbia

X

X

Florida

Georgia

X

Hawaii

X

X

X

Idaho

Illinois

X

X

X

Indiana

Iowa

X

X

Kansas

Kentucky

Louisiana

X

Maine

X

X

X

Maryland

X

X

Massachusetts

X

X

X

Michigan

X

Minnesota

X

X

X

X

X

Mississippi

Missouri

Montana

X

Nebraska

X

X

X

X

Nevada

X

New Hampshire

New Jersey

X

X

X

New Mexico

X

X

X

New York

X

X

X

North Carolina

X

North Dakota

Ohio

Oklahoma

X

Oregon

X

X

X

Pennsylvania

X

X

Rhode Island

X

X

X

South Carolina

South Dakota

Tennessee

X

Texas

X

X

Utah

X

Vermont

Virginia

X

X

Washington

X

X

X

X

X

West Virginia

Wisconsin

X

X

X

X

Wyoming

X

Total states

23

14

7

22

15

Sources: Data provided to the Urban Institute
by the Centers for Medicare and Medicaid Services as of March 2011; e-mail
communication from Tanya Broder, NILC, March 11, 2011; NILC (2007, 2010b);
Rowe et al. (2010).
a. State provides assistance to lawfully present children and/or pregnant
women with federal/state funding under Medicaid and/or CHIP. Data provided
to the Urban Institute by the Centers for Medicare and Medicaid Services
in December 2010 and supplemented in March 2011.
b. State covers pregnant women regardless of their immigration status
under the CHIP unborn child option. Data provided to the Urban Institute
by the Centers for Medicare and Medicaid Services in January 2011.
c. State provides state-only-funded food assistance to some or all
qualified immigrants during the five-year ban. Data are as of March
2011 (e-mail communication from Tanya Broder, NILC, March 11, 2011; NILC
2007).
d. State provides state-only-funded cash assistance to some or all
qualified immigrants during the five-year ban. Data are as of July
2009 (Rowe et al. 2010).
e. State provides state-only-funded health coverage to some or all
qualified immigrants during the five-year ban. Data are as of July
2010 (NILC 2010b).

The Affordable Care Act (ACA), which will expand access to subsidized health
insurance coverage for the nonelderly population, presents opportunities
for improving access to health insurance . While unauthorized immigrants
are not eligible for any of the ACA provisions, lawfully present immigrants
are eligible for the Medicaid expansion (although the five-year ban remains
in place) and for subsidies to purchase insurance at the new state health
insurance exchanges (Kenney and Huntress, forthcoming). ACA is expected
to greatly reduce the health uninsurance rate of many low-income people,
including immigrants (Kenney and Huntress, forthcoming). The expansions
in coverage and other provisions of ACA  including the development
of improved technology to support broad eligibility determinations and
streamlined enrollment, and the requirement to provide information in a
culturally and linguistically appropriate manner  could also improve
access for immigrants to human services programs, including TANF and SNAP
(Crosnoe, et. al., forthcoming; Dorn 2011; Kenney and Huntress, forthcoming).

This study was conducted by the Urban Institute under Contract Number:
HHSP23320095654WC, Task Order Number: HHSP2333014T with the HHSs
Office of Assistant Secretary for Planning and Evaluation (ASPE). The
authors take full responsibility for the accuracy of material presented
herein. The views expressed are those of the authors and should not
be attributed to ASPE or HHS.

The Urban Institute is a nonprofit, nonpartisan policy research and educational
organization that examines the social, economic, and governance challenges
facing the nation. Views expressed in this report are those of the
authors and do not necessarily reflect the views of the Institute, its trustees,
or its funders.

The authors acknowledge the helpful comments and valuable contribution to
this project of Genevieve Kenney and Olivia Golden from the Urban Institute,
Sara Lichtman Spector from the Centers for Medicaid, CHIP and Survey and
Certification, Tanya Broder from the National Immigration Law Center, and
David Nielsen and Kenneth Feingold from ASPE.

Someone born outside the United States and its territories, except those
born abroad to U.S. citizen parents. The foreign born include those
who have obtained U.S. citizenship through naturalization and other persons
in different immigration statuses. People born in the United States,
Puerto Rico, and other territories, or born abroad to U.S. citizen parents,
are native born.

Immigrant:

A foreign-born person who is not a citizen of the United States as defined
by the Immigration and Nationality Act, Section 101 et seq (similar to the
statutory term alien). This definition of immigrant is
narrower than some common definitions that treat any foreign-born person
as an immigrant, including those who have become naturalized citizens.
Since a central focus of this study is on immigrant eligibility, and citizenship
is a key factor in determining eligibility for benefit programs, this paper
adheres to the legal definition of immigrant.

Lawful permanent residents (LPRs):

People lawfully admitted to live permanently in the United States by either
qualifying for immigrant visas abroad or adjusting to permanent resident
status in the United States. Many but not all LPRs are sponsored (i.e.,
brought to the United States) by close family members or employers.

Naturalized citizens:

LPRs who have become U.S. citizens through the naturalization process.
Typically, LPRs must be in the United States for five or more years to qualify
for naturalization. Immigrants who marry citizens can qualify in three
years, and some smaller categories can qualify sooner. LPRs generally
must take a citizenship test  in English  and pass
background checks before qualifying to naturalize.

Refugees and asylees:

Persons granted legal status due to persecution or a well-founded fear of
persecution in their home countries. Refugee status is granted before
entry to the United States. Asylees usually arrive in the United States
without authorization (or overstay a valid visa), claim asylum, and are granted
asylee status once their asylum application is approved. Refugees and
asylees are eligible to apply for permanent residency after one year.

Undocumented or unauthorized immigrants:

Immigrants who are not LPRs, refugees, or asylees and have not otherwise
been granted permission under specific authorized temporary statuses for
lawful residence and work.

Lawfully present immigrants:

The term lawfully present is used for applying for Title II Social
Security benefits and is defined in the Department of Homeland Security (DHS)
regulations at 8 CFR 103.12(a). The same definition is also used by
the U.S. Department of Agriculture for determining eligibility for food stamp
benefits. In 2010, the Centers for Medicare and Medicaid (CMS) issued
a guidance to states that further defined lawfully present for
determining eligibility for Medicaid/CHIP benefits under the Childrens
Health Insurance Program Reauthorization Act of 2009 (CMS, Re:
Medicaid and CHIP Coverage of Lawfully Residing Children and
Pregnant Women, SHO # 10-006, CHIPRA #17, Center for Medicaid, CHIP,
and Survey and Certification, July 1, 2010,
https://www.cms.gov/smdl/downloads/SHO10006.pdf).
Lawfully present immigrants broadly include LPRs, refugees, and asylees,
as well as other foreign-born persons who are permitted to remain in the
United States either temporarily or indefinitely but are not LPRs.
Some lawfully present immigrants have entered for a temporary period, for
work, as students, or because of political disruption or natural disasters
in their home countries, and some may seek to adjust their status and may
have a status that allows them to remain in the country but do not have the
same rights as LPRs.

Qualified immigrants:

The following foreign-born persons are considered for eligibility for federal
benefits:

LPRs

refugees

asylees

persons paroled into the United States for at least one year

persons granted withholding of deportation or removal

persons granted conditional entry (before April 1, 1980)

battered spouses and children (with a pending or approved spousal visa or
a self-petition for relief under the Violence Against Women Act)

Cuban and Haitian entrants (nationals of Cuba and Haiti who were paroled
into the United States, applied for asylum, or are in exclusion or deportation
proceedings without a final order)

victims of severe human trafficking (since 2000, victims of trafficking and
their derivative beneficiaries [e.g., children], are eligible for federal
benefits to the same extent as refugees/asylees)

Nonqualified immigrants:

Immigrants who do not fall under the qualified immigrant groups, including
immigrants formerly considered permanently residing under color of law (PRUCOLs),
persons with temporary protected status, asylum applicants, other lawfully
present immigrants (such as students and tourists), and unauthorized immigrants.

Five-year ban:

Under TANF, SNAP, Medicaid, and CHIP, post-enactment qualified immigrants,
with important exemptions, are generally banned from receiving federal
means-tested benefits during their first five years in the United States.
Detailed immigrant eligibility criteria for these programs are provided in
the discussion and tables of the report.

Capps, Randy, Michael Fix, and Everett Henderson. 2009. Trends in
Immigrants Use of Public Assistance after Welfare Reform. In
Immigrants and Welfare: The Impact of Welfare Reform on Americas
Newcomers, edited by Michael Fix (93122). New York: Russell
Sage Foundation.

Kaiser Commission on Medicaid and the Uninsured. 2009. New Option for
States to Provide Federally Funded Medicaid and CHIP Coverage to Additional
Immigrant Children and Pregnant Women. Washington, DC: Kaiser
Family Foundation.
http://www.kff.org/medicaid/upload/7933.pdf.

[1] An immigrant is a foreign-born
person who is not a citizen of the United States per the Immigration and
Nationality Act, Section 101 et seq. See Figure 5
for other definitions.

[2] The Food Stamp Programs
name was changed to the Special Nutrition Assistance Program in 2008.

[3] This brief focuses on TANF,
SNAP, Medicaid, and CHIP. Supplemental Security Income (SSI), Medicare, Social
Security, the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC), Child Care and Development Block Grant services, and
other federal programs are outside the scope of the project.

[4] In addition to programs necessary
to protect life or safety, nonqualified immigrants, regardless of status,
are eligible for some other programs, such as WIC and school breakfast and
lunch programs for children. Nonqualified immigrants are also eligible for
emergency Medicaid if they are otherwise eligible for their states
Medicaid program.

[7] For the definition of lawfully
present immigrants, see A HREF="#fig5">Figure 5. Immigrants must
also meet the Medicaid state residency requirement (CMS, Re:
Medicaid and CHIP Coverage of Lawfully Residing Children and
Pregnant Women; NILC 2010a).

[8] A state may only elect coverage
in its separate CHIP program if the state has also elected to cover the same
population in its Medicaid program. See also CMS, Re: Medicaid
and CHIP Coverage of Lawfully Residing Children and Pregnant
Women.

[9] The state eligibility provisions
are a summary based on recent publicly available information. They
alone should not be used for assessing the policy options available to a
state under federal law.

[11] NILC also lists Tennessee
(under the Family First program) and Vermont (under the Reach Up program)
as providing state-funded cash assistance to qualified immigrants during
the five-year ban (NILC 2008). Alaska, Colorado, and North Dakota provide
state-funded cash assistance to certain American Indians born in Canada who
can be regarded as qualified immigrants for purposes of eligibility.
These states do not provide assistance to other qualified immigrants.

[12] A few additional states
have pending state plan amendments to provide medical coverage to children
and/or pregnant women: Pennsylvania and Illinois through Medicaid,
and Delaware, Illinois, Maine, Massachusetts, Montana, and Nebraska through
CHIP (NILC 2010b, 2010c). Data provided to the Urban Institute by the
Centers for Medicare and Medicaid Services in December 2010 and supplemented
in March 2011.